Wednesday, February 1, 2012

Educative Journalism in Massachusetts

Apropos yesterday's post, this editorial from today's Boston Globe is interesting. I've interlaced comments of my own in bold italics:

EVEN BEFORE this year’s grand debate about containing health care costs begins on Beacon Hill, a pointed disagreement has broken out among key players in the state health care arena.

The health plans fear that legislative meddling is opening holes in the very cost-controlling arrangements that a recent law required, while legislators contend they are simply looking out for individuals who might be hurt by policy changes. The editorial makes clear that this is a classic "good vs good" conflict. Constraining costs is an ethical responsibility, since health care costs deplete wages, small business viability, and the state's capacity to fund other public goods. But protecting vulnerable people from unintended impacts of policy decisions is also an ethical responsibility.

There is nothing wrong with trying to minimize disruptions on patients from changes to their insurance plans, but the recent proposal to give certain patients the right to keep receiving treatment at higher-cost hospitals is too broadly written. Until it is clear just how many people would be exempted from policy changes, and how that might add to insurers’ costs, the Legislature should hold off, lest it undermine its own goal of making health care more affordable. If I'd written the editorial I wouldn't have used the phrase "insurers' costs." Those costs are passed through to the businesses and public agencies that purchase insurance. The public doesn't always understand that health plans - especially the regional not-for-profit health plans Massachusetts has - are essentially purchasing agents for the public and private entitites that provide health insurance to their constituents.

The year before last, the Legislature passed a law requiring insurers to offer limited networks, which restrict plan members to certain hospitals and doctors, and tiered networks, which charge plan members more for using more expensive providers. The moves provided lower-cost insurance options for families and businesses, albeit by limiting patients’ choices of doctors and hospitals. Over the past two years, average annual premium hikes have shrunk from a projected 16.3 percent to 2.3 percent.

But this year, at the behest of Representative Steven Walsh, House chairman of the Joint Committee on Health Care Financing, and other influential legislators, the Legislature passed a budget rider making exceptions for some members of such plans. Walsh says he’s concerned that patients who were undergoing treatment at Children’s Hospital, the Dana-Farber Cancer Institute, and the Floating Hospital under the terms of their previous plans be able to continue their treatments there without bearing large cost increases. He contends that the budget language is crafted to apply to only a relatively small number of patients; he doesn’t, however, have a reliable estimate of just how many.

Although the legislative intentions may well be good, this episode is a cautionary tale.

The insurers, for their part, worry the language would allow a much larger number of patients with chronic conditions to sidestep plan features designed to rein in costs. They also worry that this action sets a bad precedent for future legislative interventions; already, lobbyists for major hospitals are seeking ways to keep their patients while still receiving higher reimbursements from insurers. It will likely now be left to the Patrick administration to work out a compromise.

Although the legislative intentions may well be good, this episode is a cautionary tale. Health care policy is so complex, and with so many moving parts, that it’s best to work out problems beforehand rather than fix them later. In this case, it’s easy to imagine a relatively small number of people with serious illnesses in the midst of rigorous treatment at Children’s, Dana-Farber, or Floating Hospital having a legitimate need to continue seeing the same doctors. I know from research I've done on the appeals process that continuity of care is a common concern for patients and clinicians. When you look at individual situations in detail it's clear that there's a continuum from long term/high complexity treatments in which deep relationships have been created over time to relatively clear cut treatments that could quite reasonably be transferred to another site. The editorial writer(s) recognize this continuum and make a nuanced argument.

But until Walsh and other sponsors can say just how many beneficiaries there are, and be certain that other patients will not be able to use the law to get treatment at their institution of choice without having paid for that option, the Legislature should avoid meddling with a reform that truly has worked.

This is a thoughtful, well-informed editorial. This kind of educative journalism has been an important contributor to the relatively collaborative way in which the state is dealing with the volatile conflicts that any serious health reform effort must tackle.